What are some of the issues that come up for cancer patients after treatment?

Dr. Asher: There are physical issues and then there are psychological, emotional, and spiritual issues. In the physical domain, the most common complaint by far is fatigue, which may not seem very significant, but it often has a psychological component. It is consistently a major issue in cancer quality-of-life studies. Fatigue tends to be the most distressing symptom of all of the different symptoms that cancer patients go through.

Not pain?

Dr. Asher: We generally do a much better job of managing pain. And not everyone has pain. For example, of those with metastatic prostate cancer all over their bones, only 22% or so have pain, whereas fatigue is ubiquitous. Whether you’re going through chemo for breast cancer, prostate cancer, pancreatic cancer, or any other type of cancer, it is almost impossible not to experience some fatigue. Fatigue is what really keeps people from doing things that are meaningful and important to them, so it tends to be the most distressing symptom, perhaps because it’s so common.

Is fatigue always directly associated with a treatment, or is that fatigue due to treatment plus any stress, anxiety, or depression the person may be having about the fact that they have cancer?

Dr. Asher: This is why I find this a fascinating problem: it may involve all of these facets together. It could be just the cancer itself, so you could have fatigue before you even start any treatment. Clearly, chemo and radiation cause fatigue. And it could also be the emotional stress— not sleeping well, nutrition changes, and being in pain all the time. It’s exhausting. Depression and fatigue have a lot of overlap, and the challenge is teasing apart all of these different factors and coming up with a plan once you sort them out.

Are there any other issues common to multiple cancers?

Dr. Asher: Everyone has fear of something, though fears may be different. For some, it just may be the fear of death, fear of the unknown, or fear of becoming dependent. Many fear losing independence and having to rely on or burdening their loved ones. This kind of fear is quite common.

In the cancer world, you hear a lot of talk about stress, but you very rarely hear people talk directly about fear. Is stress a code word for fear? Or is it different?

More and more studies show that stress doesn’t really hurt us or kill us, but our perception of stress is more impactful. Studies show that people who perceive stress as something that allows them to rise to the occasion, perform better, or overcome a challenge tend to have higher survival rates. If someone views stress as something that’s going to hurt and negatively impact them, that perspective tends to have a spiral effect and is associated with higher mortality rates.

Over and over, studies show that chronic loneliness is associated with a poorer cancer prognosis. Chronic loneliness is a more negative risk factor than this loose idea of stress, which is so dependent upon one’s personal interpretation of the phenomenon. I guess you could tease out stress to be both fear and loneliness, though. Dr. Asher: It could be fear. It could be loneliness. It could be a sense of poor self-efficacy.